Treating insomnia associated with cancer: a randomised, multi-centre trial of cognitive behaviour therapy (CBT) delivered by cancer nurse specialists

Background: Sleep disturbance is commonly associated with cancer either as a new presentation or an exacerbation of previous sleep difficulties. Often sleep disturbance is short-term, but in 25% of cases it is persistent impacting upon quality of life. Aims: The purpose of this study was to investigate the efficacy of a non-pharmacological intervention to reduce clinical complaints of severe insomnia and to improve quality of daytime functioning. An associated aim was to determine the feasibility of applying this approach in oncology when delivered by cancer nurse specialists. Methods: The study conformed to a pragmatic randomised trial with participants allocated in a 2:1 ratio to CBT or treatment as usual (TAU) in two centres, the Beatson Oncology Centre in Glasgow and the Anchor Unit at Aberdeen Royal Infirmary. All participants met clinical and research diagnostic criteria for insomnia associated with a medical condition. In all cases the insomnia had become a chronic problem, persisting after active anti-cancer therapy. CBT was delivered according to a treatment manual across five, small group sessions. Primary outcomes were subjectively assessed sleep (diary) and objectively estimated sleep (actigraphy) at post-treatment and 6 month follow up. Results: 150 eligible participants were randomised to CBT (100) and TAU (50). The majority had had breast, prostate or colorectal cancers, on average 4 years prior to participation. Mean age of the sample was 61 years. CBT was associated with an average reduction in sleep-onset latency plus wake time after sleep onset of 60 minutes per night of sleep, relative to little change in TAU. Importantly, demographic and clinical factors did not contraindicate response to this form of insomnia treatment. Daytime improvements in health-related QoL and reductions in fatigue were also obtained following CBT. The treatment programme appeared both feasible and acceptable in practice. Conclusions: Insomnia frequently presents at times of stress and endures as a chronic problem. The results from this trial conducted in oncology suggest that effective, practical help can be provided at relatively small cost to improve the sleep pattern and sleep quality of people with severe and persistent insomnia. The potential of nurse specialists and clinical psychologists to work together in delivering this important aspect of psychological care is considerable. Acknowledgements: Supported by a grant from Cancer Research UK (C8265/A3036).